JOB OBJECTIVE

The Customer Service Representative handles customer service inquires and problems via telephone, email or written correspondence. Answers questions and resolves issues based on phone calls/letters from members, providers and plan sponsors. Explains member’s benefits, rights and responsibilities in accordance with contract and uses applicable system tools and resources to produce quality letters and spreadsheets in response to inquiries received.

ESSENTIAL DUTIES AND RESPONSIBILITIES INCLUDE:

The Customer Service Representative will be responsible for:

• Provide exceptional customer service via telephone
• Adjust greeting to real time environment displaying empathy for the member’s inquiry
• and/or situation
• Ensures customer satisfaction by providing quality service, identifying customer needs and assisting them with issues/concerns related to insurance benefits, provider contracts, eligibility and claims.
• Deliver accurate, concise information that result in the member feeling confident that the service request has been understood and resolved.
• Analyze problems and resolve the Provider, Member and Health Plan issues over the telephone on the first call as often as possible.
• Research, identify and problem solve, verify eligibility of service and place call backs as required. Assure timely follow-up and set appropriate expectations on all pending cases.
• Ensure Provider Claims Inquiries are resolved timely.
• Thoroughly documents inquiry outcomes for accurate tracking and analysis. Develops and maintains positive customer relations and coordinates with various functions within the company to ensure customer requests and questions are handled appropriately and in a timely manner.
• Seeks, understands and responds to the needs and expectations of internal and external customers. Provides external and internal customers with requested information.
• Maintain key performance metrics on outbound/inbound calling programs. Meet and support established service goals and business objectives by meeting and exceeding performance standards.
• Adapts communication style to persons representing diverse personal, professional, cultural, and socio-economic backgrounds.
• Ability to multi-task; simultaneously thinks, talks, and types.
• Uses excellent hearing and listening skills to receive detailed information while utilizing good probing skills.
• Requires knowledge of company services, products, insurance benefits, provider contracts and claims.
• Perform other duties as assigned including participation in all safety programs which may include assignment to an emergency response team.